Editorial

Healthcare in the United States and across the world continues
to face unique challenges. While these challenges and even
methods/technology for meeting these challenges change, the
central goal remains the same, to improve the health and wellbeing
of people, all people. One unique aspect of health care
delivery is the prevalence of health disparities. Multiple
definitions exist for a health disparity, a working description
was stated by Warnecke et al. [1], “A difference may become a
disparity when some subgroups and not others are given access
to resources to manage their differential risk from biological or
other factors and the groups without access have poorer
outcomes.” As efforts continue to address the complex issues
associated with health disparities, several notable conferences
are dedicated to discussing problems and potential solutions.
The corresponding author enjoys these conferences and
learning about the tremendous work being done in the field.
His attendance also raises questions about the makeup of the
attendees–more specifically, where were the STEM
researchers? What is the theory behind why these proposed
interventions were designed the way they were? Can these
interventions by further optimized? Yes perhaps as engineering,
the author’s mind frequently frames problems in terms of the
engineering design or scientific methods. Such viewpoints may
be helpful. To accelerate the development of solutions for
complex health disparities, multiple disciplinary approaches
that leverage STEM expertise must be included in the
discussion. In short, STEM researchers must engage more in
the area of health disparities research.

Sufficient multilevel interventions are necessary in order for
health disparities to be eradicated. Meaning patients, healthcare
systems, healthcare providers, the community, as well as
lawmakers need to be on the same page in order for a longlasting,
impactful intervention to be successful. Health
disparities begin when a patient sees a physician. The patient
and physician have an interaction on what is problematic for
the patient. Often a prescription is given or a treatment plan is
made. This process is not the same for racial/ethnic minority
patient due to an implicit bias a physician may have about
them. Implicit bias refers to the stereotypes or attitudes
affecting our understanding, actions, and decisions in an
unconscious manner. Such a bias is the leading cause of health
disparities. The implicit bias the providers have is due to their
culture and how they were taught to view certain people.
Physicians may allow implicit bias to sway their decisions on
how to medically and morally treat their minority patients. This
type of bias delays the patient’s treatment and deepens the bias
the physician has for them. Multiple interactions in biased environments worsen the patient’s disease state. The physician
then may note the patient is not compliant and less cooperative.
The patient’s age, gender, income and education level do not
matter; due to their racial/ethnic minority status, their provider
has an implicit bias against them. Changing this narrative
begins with the provider’s medical education. One way to
intervene on these implicit biases providers have, culturally
responsive healthcare is necessary [2]. Future physicians
should undergo cultural competency training prior to becoming
licensed. This training can decrease the implicit bias an
individual may have. A few states already have this law in
place as a requirement for licensure and a few medical schools
are working on adding cultural competency to their
curriculums.

Multilevel interventions exist beyond patient-provider
interactions. This can be seen in two interventions outlined by
Paskett: one dealt with cervical cancer disparities and the other
with cardiovascular disease disparities [3]. With the cervical
cancer disparities in Appalachian Ohio, the intervention to
increase the rate of Human Papilloma Virus (HPV)
vaccinations and decrease the rate of cervical cancer was on
three levels: the health system encouragement (1), regular staff
meetings with HPV presentations (2), educating parents with
daughters (3). In the end, the intervention was considered
successful because number of girls receiving the first
vaccination of the series increased; however, the total number
of girls receiving the vaccination was low. A cardiovascular
disease intervention introduced healthy food choices in the
front of four neighborhood corner stores in East Los Angeles
and Boyle Heights. The intervention involved the entire
community, minus policy makers. Within a two-year span,
there was no significant change in healthy food consumption;
however perceptions of fresh food availability improved. Both
interventions proved the beneficial, however, the impact of
multilevel interventions is still an underdeveloped area.

Researchers in STEM fields need to become more involved in
the intervention process as well. Health fairs are commonplace
in underserved communities, however, very few providers or
researchers speak with community members about new
treatments or clinical trials they may be eligible for. Clinical
trials are beneficial to both the researcher as well as the patient:
the researcher is able to have data and the patient has access to
free healthcare (depending on the extent of the research) and
they are usually compensated for their time. Insurance
companies could be present to provide information and answer
questions for community members as well.

Patients and their families want consideration of the whole
person as opposed to an isolated focus on the disease. Interventions must provide information on resources available
in their community [4]. The Delaware Cancer Treatment
Program provides an excellent example of multidisciplinary
mechanisms working together to create a successful multilevel
intervention. This program was created in 2004 through
legislation to give Delaware-residents access to universal
treatment and screening of colorectal cancer. This program
gives patient’s assistance during the entire process. Carecoordination
and case-management is available to everyone
within the state even if the patient does not have insurance.
Since its inception, the Cancer Treatment Program has
eliminated disparities in screening and rates of incidence.

The literature has shown a sincere appreciation for the
multifactorial and multi lever level nature of Health disparity
problems. Much of the success found in these interventions
stems from the interdisciplinary of the teams that developed
these interventions. Various disciplines within Engineering
focus on systems (e.g. systems engineering) this expertise
should be applied towards the development of system wide
interventions. Similar to scientists, technologists, and
mathematicians, engineers have experience with complex,
multifaceted problems and want unique opportunities to
contribute beyond medical in laboratories. We believe one of
the barrier towards greater involvement of engineers in health
disparities research, is the engineers’ lack of knowledge about
health disparities, and a lack of understanding within the health
disparities community regarding engineering. Interdisciplinary
workshops, conferences, and collaborations involving people
from multiple disciplines can meet, discuss, learn, and
eventually solve challenging problems, would address the gap
between research teams. Another challenge is the lack of
translation of many key concepts in STEM research. A
significant portion of STEM research is rightfully theoretical,
in order to generate the new knowledge that leads to new
solutions. The need for more immediate solutions. Medical
research and innovation has a history of application-based
solutions that grew from theoretical research. Therefore,
STEM researchers are well equipped to translate new
knowledge into solutions. While time to generate a solution is
a concern, I believe it greater involvement of STEM research
would not add significant time to the current process. Current
interventions involve extensive research and development.
STEM research can work in parallel with existing intervention
designs, shortening the time until launch.

Many may argue that enough STEM based interventions exist,
why should STEM researchers invest more into this area?
Examples of innovative solutions are found in recent
developments related to mobile health (mHealth). mHealth
technologies have created new and accessible platforms
providing vast amounts of healthcare information to users,
regarding one’s own health status as well as general
information about healthcare related questions. mHealth has
also presented opportunities for unprecedented access to
healthcare providers. Even with the promise of mHealth
technology, disparities still exist. Sarkar et al. [5,6] looked at
the impact of internet portals on improving patient literacy.
Patients used a new resource (i.e. a portal with information about patient health). The intervention had limited impact, as
many individuals with perceived lower health literacy levels,
never accessed the resource. A follow-up study suggested the
lack of use of new resources stems from the digital divide, as
well as other significant issues extending beyond access to
technology. Therefore, solving technical issues alone via the
mantra “If you build it they will come” does not address the
complexities of health disparities. STEM alone cannot solve
Health disparity issues. Socioeconomic and political issues
must also be addressed.

Even with the tremendous strides in healthcare and medical
technology, society recognizes the increased complexities,
facing human health. Significant levels of effort translated into
innovative approaches for addressing health disparities as seen
in many multilevel interventions. Many interventions were
launched via interdisciplinary partnerships including STEM
researchers. To continue such innovation, STEM researchers
must increase our involvement in health disparities research
and the development of future interventions. In doing so, we
will directly support the missions of the NSF “…to advance the
national health…” and the NIH “…to uncover new knowledge
that will lead to better health for everyone…”

References

Warnecke RB. Approaching health disparities from a population perspective: The National Institutes of Health Centers for Population Health and Health Disparities. Am J public health. 2008;98:1608-15.

Klonoff EA. Disparities in the provision of medical care: An outcome in search of an explanation. J behav med 2009;32:48.

Sarkar U. The literacy divide: health literacy and the use of an internet-based patient portal in an integrated health system-results from the Diabetes Study of Northern California (DISTANCE). J health commun 2010;15:183-96.